CMS/EIP Fiscal Report Statewide
Services beginning 07/01/2012 ending 09/30/2012 Date of Report:11/16/2012 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 176 404.750000 14920.2500 36.8629
Subtotal (Total Children Is Unduplicated) 176 404.750000 14920.2500 36.8629
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-TRANSITION ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 18.000000 999.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 16.000000 1200.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 48.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 6 6.000000 291.0000 48.5000
Subtotal (Total Children Is Unduplicated) 28 57.000000 3648.0000 64.0000
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 7 18.000000 6072.8400 337.3800
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT ITDS, FACE TO FACE 14 9.500000 475.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 2 1.000000 25.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 4 4.000000 100.0000 25.0000
EIGF-EIGF_NM-EI GROUP SESSION BY NONMED PROF 6 376.000000 9400.0000 25.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 37 849.000000 21225.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 42.750000 2137.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 14.500000 984.2600 67.8800
PHY-97110-PT SESSION BY LICENSED PT 10 9.500000 644.8600 67.8800
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 54.3200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 14.493900 983.8500 67.8803
TRAV-TRAV-PROVIDER TRAVEL TO NATURAL ENVIRONMENT 37 1822.000000 912.5000 0.5008
VISN-EIIF_NM-EI VISION SERVICES, IND NONMED 21 367.000000 18350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 150 3533.243900 61590.1300 17.4316
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Total 3994.993900 80158.3800 20.0647
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Number of Children (Unduplicated) With at Least One Service 351
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
52 376.250000 20015.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 52 376.250000 20015.2500 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
6 10.000000 4453.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6 10.000000 4453.8400 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
69 1070.250000 27674.4100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 69 1070.250000 27674.4100 0.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3 6.000000 411.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3 6.000000 411.0000 0.0000
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
240 570.500000 8178.2500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 240 570.500000 8178.2500 0.0000
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 3.000000 200.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2 3.000000 200.0000 0.0000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.500000 33.9400 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
101 1190.493900 3979.3200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 102 1190.993900 4013.2600 0.0000
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
251 190.500000 7096.7700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 251 190.500000 7096.7700 0.0000
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
43 222.000000 7188.3200 0.0000
Other 23 355.500000 927.2800 927.2800
---------------------------------------------------------
Total 66 577.500000 8115.6000 927.2800